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Underground Storage Tank Program - Farm Tank Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACT NAME <br /> A C. Je Jong Trucking Inc. Larry <br /> C ADDRESS(Street address of TANK location) PHONE N (with area code) <br /> I 24975 South Austin Rd. (209) 599-4187 <br /> L <br /> I CITY STATE ZIP CODE I NEAREST CROSS STREET <br /> T Ripon, CA CA 95366 West Ripon Rd. <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION&ADDRESS (Complete If Information different from above.) <br /> 0 ";AME OPERAT Cf NOMI'. <br /> P Same , s, <br /> E MAILING or STREET ADDRESS OPERATOR f]10NrsN (w- area code) <br /> �Tf S 17 1. - <br /> R J� <br /> A <br /> lfT <br /> CITY S1'A"fG LIP CODE r�r`G•, <br /> �6U <br /> o �i( <br /> R CHECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME OWN Fit CONTACT NAME' <br /> 0 C. De Jong Core De Jong <br /> NMAILING or STREET ADDRESS OWNER PHONE N(with area code) <br /> E 24975 SouthAustin Rd. (209) 599-3289 <br /> R CITY Ripon, CA STALE ZIP CODE <br /> CA 95366 <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site = to or < 1,100 gallon capacity) <br /> E X PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS ut site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION (List additional tank Information on separate sheet if needed.) <br /> T TANKSIZE CHEMICALS STORED ESTIMATED DATE LAST USED MET110DOFCLOSURE DA'ITi OF REMOVAL Olt <br /> A (GALLONS) CURRENTLYORPREVIOUSLY IF CUIUtENILY EMPTY IF PERMANENTLY CLOSED CLOSUIUi IN PLACE <br /> N <br /> K 10,000 GAL Diesel Dug Up 1979 <br /> 1 1 ,100 GAL Gasolane Dug Up 1979 <br /> N <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED U DER PENALTY OF PERJURY,AND TO TILE BEST OF MY KNOWLEDGE,IS TRUE AND CO11REUI'. <br /> NAME ., <br /> DATE <br /> TITLE <br /> . ?d <br /> OFFICE USE ONLY <br /> SWUEPSM I MMPM IOCCODEDIS'1'CODEaACIIVEUG'1MULEMPTUG'I' MCIOSEDUGT SWllil'SPItGM/SUUCODE UAl'li <br /> Ell 23 044(12/88) <br />